Rosen & Barkin's 5-Minute Emergency Medicine Consult (763 page)

• Primary ventricular dysrhythmias are extremely rare in children.
  
• VF usually results from a respiratory arrest, hypothermia, or near drowning.
  

DIAGNOSIS

• Loss of consciousness
  
• Seizure
  
• Transient gasping followed by apnea
  
• Absent pulse and heart sounds
  
• Death if the rhythm remains untreated:
  
  • VF is the initial rhythm in ∼5–70% of patients sustaining sudden cardiac death in the pre-hospital setting
    

• AED or manual defibrillator to confirm and treat a shockable rhythm
  
• Cardiac monitor
  

• Lab tests are not useful during resuscitation
  
• After return of spontaneous circulation (ROSC): Electrolytes including calcium and magnesium, BUN, creatinine, troponin, ABG, lactic acid level, and toxicology screen
  

• After ROSC
  
• To identify cause of VF:
  
  • EKG
    
  • Cardiac US
    
  • CXR, also to monitor placement of an endotracheal tube (ETT)
    

• Asystole:
  
  • Fine VF may mimic asystole in a single lead.
    
  • Check rhythm in another lead for fine fibrillations
    

TREATMENT

• Escalating biphasic energy levels have been shown to improve conversion of VF:
  
  • Almost all automated external defibrillators (AED) and manual defibrillators commercially available are biphasic
    
  • Biphasic defibrillators are recommended because less energy is required
    
• Some study raised questions on the benefit of epinephrine in cardiac arrest
  
• The benefit of amiodarone or lidocaine in post cardiac arrest after ROSC is uncertain
  
• The benefit of procainamide as a 2nd-line antiarrhythmic remains controversial and is no longer included in the AHA guidelines
  

• Promptly recognize cardiac arrest
  
• Follow initial stabilization/therapy
  
• Ideally, transport to the closest facility delivering comprehensive post cardiac arrest treatment
  

• Use AED or manual defibrillator as soon as available
  
• Perform early CPR starting with chest compressions until defibrillator is ready
  
• Defibrillator confirms shockable rhythm
  
• Initiate SCREAM acronym
  
• Shock:
  
  • Immediate defibrillation with 1 shock
    
  • Biphasic energy level:
    
    • Follow manufacturer’s recommendations (e.g. 120–200 J) for 1st shock; if unknown, use maximum available
      
    • Same or higher energy for subsequent shocks
      
  • 360 J monophasic for 1st and subsequent shocks
    
  • May repeat q2min until rhythm changes
    
• CPR:
  
  • Immediately resume CPR after each shock for 2 min starting with chest compressions
    
  • 30:2 compression–ventilation ratio if no advanced airway in place
    
  • ≥100 compressions per minute
    
  • Minimize CPR interruptions
    
• Rhythm
  check after every 2 min of CPR
  
• Secondary ABCD survey to try and determine underlying cause while resuscitation in progress
  
• Establish IV/IO access
  
• Epinephrine
  if defibrillation is unsuccessful:
  
  • Start after 2nd shock
    
  • May repeat q3–5min
    
  • Vasopressin may replace 1st or 2nd dose of epinephrine
    
• Antiarrhythmic medications
  if refractory VF:
  
  • Start after 3rd shock
    
  • Amiodarone
    
  • Lidocaine if amiodarone is not available
    
  • Magnesium for torsade de pointes
    
  • May consider a continuous infusion of the antiarrhythmic agent associated with ROSC
    
• Advanced airway management:
  
  • Should not delay initial CPR and defibrillation
    
  • Resume CPR with continuous chest compressions ≥100/min and 1 ventilation every 6–8 sec
    
  • Use capnography to monitor ETT position, optimize quality of CPR, and detect ROSC
    

• Defibrillation sequence: Monophasic 2 J/kg, 2–4 J/kg, 4 J/kg
  
• May consider 4–10 J/kg or adult maximum dose for subsequent shocks
  

• Post cardiac arrest care
  
• Identify and treat the cause of the VF arrest recognizing that the most likely cause is acute myocardial infarction:
  
  • Provide percutaneous coronary intervention when indicated
    
• Maintain SpO
  ₂
  ≥94% and PETCO
  ₂
  at 35–40 mm Hg
  
• Treat SBP <90 mm Hg
  
• Maintain body temperature at 32–34ºC
  
• Treat hyperglycemia >180 mg/dL (>10 mmol/L)
  

• Epinephrine: 1 mg IV/IO bolus, may repeat dose q3–5min
  
• Vasopressin: 40 U IV/IO bolus single dose
  
• Amiodarone: 300 mg in IV/IO bolus, may repeat 150 mg IV/IO bolus once:
  
  • Amiodarone infusion after ROSC: 1 mg/min for 1st 6 hr then 0.5 mg/min for 18 hr. Max. cumulative dose 2.2 g/24 h
    
• Lidocaine: 1–1.5 mg/kg IV/IO bolus, may repeat 0.5–0.75 mg/kg IV bolus q5–10min; 3 doses max. or max. cumulative dose 3 mg/kg:
  
  • Lidocaine infusion after ROSC: 1–4 mg/min (30–50 μg/kg/min)
    
• Magnesium sulfate: 1–2 g in 10 mL D
  ₅
  W IV/IO bolus
  
• Follow each medication with a 20 mL NS flush.
  

• Epinephrine: 0.01 mg/kg IV/IO, may repeat q3–5min; max. cumulative dose 1mg
  
• Amiodarone: 5 mg/kg IV/IO, may repeat 5 mg/kg; max. cumulative dose 15 mg/kg/d
  
• Lidocaine: 1 mg/kg IV/IO:
  
  • Lidocaine infusion 20–50 μg/kg/min
    
• Magnesium sulfate: 25–50 mg/kg IV/IO up to 2 g
  
• Follow each medication with a 3–5 mL NS flush.
  

FOLLOW-UP

All patients who survive need admission to the ICU/CCU.

No patient who suffers a VF arrest may be discharged from the ED.

Patients with episodes of VF occurring >48 hr post-MI may need referral to electrophysiology.

ACC/AHA guidelines recommend that patients with an acute myocardial infarction should have their serum potassium maintained above 4 mEq/L to prevent ventricular dysrhythmias

• de Jong JS, Marsman RF, Henriques JP, et al. Prognosis among survivors of primary ventricular fibrillation in the percutaneous coronary intervention era.
  Am Heart J
  . 2009;158:467–472.
  
• Hagihara A, Hasegawa M, Abe T, et al. Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest.
  JAMA.
  2012;307:1161–1168.
  
• Hazinski MF, Nolan JP, Billi JE, et al. Part 1: Executive summary: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.
  Circulation
  . 2010;122(16 suppl 2):S250–S275.
  
• Morrison LJ, Deakin CD, Morley PT, et al. Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.
  Circulation
  . 2010;122(16 suppl 2):S345–S421.
  
• Zipes DP, Camm AJ, Borggrefe M, et al. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death.
  Circulation.
  2006;114:e385–e484.
  

See Also (Topic, Algorithm, Electronic Media Element)

2010 ACLS Guidelines

CODES